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Authorization For Release Of Confidential Information

Client Name:
Address:
City:   State:   Zip:
Date of Birth:   Social Security Number: XXX-XX-

1. I authorize TIDES OF LIFE to:
Name of Organization/Person:
Address:
City:   State:   Zip:
Phone:   FAX:

2. The purpose of this disclosure:
*Continuity of Care
*Coordinate EAP benefits
*Billing
Medical Planning
Verify Attendance
Obtain Insurance Authorization
Attorney
Other

3. Description of the Information to be released (Choose one):
*All information contained within the Medical Records including information regarding drug and alcohol, mental health and AIDS related records.
Only Specified Records:

4. I understand that this authorization may be revoked at any time and will expire upon the occurrence of the following condition or date. (Choose one):
*60 days past the termination of services at Tides of Life
This Date: (A future date must be selected with this option)

5. By checking this box and entering my name below I agree that all of the above is true.
Name:   Date:

This information has been disclosed to you from records protected by the Federal Confidentiality Rules (42 CFR Part 2). These Federal rules prohibit you from making any further disclosure of this information, unless further disclosure is expressly permitted by the patient or as otherwise permitted by the 42 CFR Oar 2. A general authorization for the release of is information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any drug or alcohol patient.